This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.bcbsga.com/usg or by calling 1-800-424-8950. Important Questions Answers Why this Matters: What is the overall deductible? $0 Are there other deductibles for specific services? Is there an out of pocket limit on my expenses? Separate out of pocket for medical and pharmacy. What is not included in the out of pocket limit? Is there an overall annual limit on what the plan pays? Does this plan use a network of providers? No Medical (BCBSGa): Individual $5,500 / Family $9,900 Pharmacy (CVS/Caremark) $1,100 Employee/ $2,200 Two covered members /$3,300 Family Premiums and health care this plan doesn t cover. No Yes, BlueChoice HMO network See www.bcbsga.com/usg or call 1-800-424-8950 for a list of participating providers. (Plan participants must use network providers to receive benefit coverage, except in an emergency.) See the chart on page 2 for your costs for services this plan covers. You don t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Even though you pay these expenses, they don t count toward the out-of-pocket limit. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. 1 of 9
Do I need a referral to see a specialist? Are there services this plan doesn t cover? Yes. (Your primary care physician will issue a referral to a network specialist as needed.) Yes. This plan will pay some or all of the costs to see a specialist for covered services but only if you have the plan s permission before you see the specialist. Some of the services this plan doesn t cover are listed on page 4. See your policy or plan document for additional information about excluded services. Copayments are fixed dollar amounts (for example, $20) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use participating providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event If you visit a health care provider s office or clinic If you have a test Services You May Need You Use an In- Network You Use an Out-of-Network Limitations & Exceptions Primary care visit to treat an injury or illness $30 copay/visit Not Covered none Specialist visit $50 copay/visit Not Covered none Other practitioner office visit $50 copay/visit for chiropractic care Not Covered Limit of 20 visits per calendar year. Preventive care/screening/immunization No Charge Not Covered Based on age appropriate guidelines Diagnostic test (x-ray, blood work) No Charge Not Covered none Imaging (CT/PET scans, MRIs) No Charge Not Covered none 2 of 9
Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available by contacting your pharmacy vendor, CVS Caremark at 877-362-3922 If you have outpatient surgery If you need immediate medical attention If you have a hospital stay Services You May Need Retail generic drugs / Mail order generic drugs Retail preferred brand drugs / Mail order preferred brand You Use an In- Network $10 /$25 copay per prescription $35/$87.50 copay per prescription You Use an Out-of-Network Not Covered Not Covered Non-preferred brand drugs 20% coinsurance Not Covered Specialty drugs CVS/Caremark 877-362-3922 Not Covered Limitations & Exceptions Up to a 30 day supply allowed. Mail order and 90 day supply (maintenance) available. Retail, $45 minimum and $125 maximum cost share // Mail order, $112.50 minimum and $250 maximum none Facility fee (e.g., ambulatory surgery center) $200 copay/visit Not Covered none Physician/surgeon fees No Charge Not Covered none Emergency room services $250 copay/visit $250 copay/visit Out-of-network coverage only in an emergency. Emergency medical transportation No Charge No Charge Out-of-network coverage only in an emergency. Urgent care $50 copay/visit Not Covered none Facility fee (e.g., hospital room) $500 copay/visit Not Covered none Physician/surgeon fee No Charge Not Covered none 3 of 9
Common Medical Event If you have mental health, behavioral health, or substance abuse needs You may call (800) 292-2879 for questions If you are pregnant If you need help recovering or have other special health needs If your child needs dental or eye care Services You May Need You Use an In- Network You Use an Out-of-Network Limitations & Exceptions Mental/Behavioral health outpatient services $30 copay /visit Not Covered none Mental/Behavioral health inpatient services $500 copay/visit Not Covered none Substance use disorder outpatient services $30 copay/ visit Not Covered none Substance use disorder inpatient services $500 copay/visit Not Covered none Prenatal and postnatal care $50 copay/visit Not Covered Copay is for first visit only. Delivery and all inpatient services $500 copay for Emergency coverage available out-ofnetwork. Not Covered facility fees Home health care No Charge Not Covered Limited to 120 visits/calendar year. Speech therapy has a 30 visit limit; Rehabilitation services $50 copay/visit Not Covered physical and occupational therapy has a 40 visit limit. All rehabilitation and habilitation visits Habilitation services $50 copay/visit Not Covered count toward your rehabilitation visit limit. Skilled nursing care No Charge Not Covered Skilled nursing facility has a 30 day limit per calendar year. Durable medical equipment No Charge Not Covered none Hospice service No Charge Not Covered none Eye exam Not Covered Not Covered none Glasses Not Covered Not Covered none Dental check-up Not Covered Not Covered none 4 of 9
Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn t a complete list. Check your policy or plan document for other excluded services.) Acupuncture Bariatric surgery Cosmetic surgery Dental care (Adult) Hearing aids Infertility treatment Long-term care Non-emergency care when traveling outside the U.S. Routine foot care Weight loss programs Some behavioral health issues Private duty nursing Other Covered Services (This isn t a complete list. Check your policy or plan document for other covered services and your costs for these services.) Chiropractic care Coverage provided outside the United States. See www.bcbs.com/bluecardworldwide Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact your local HR department. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov. 5 of 9
Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact: Blue Cross Blue Shield of Georgia PO Box 105449 Atlanta, GA 30348-5449 Additionally, a consumer assistance program can help you file your appeal. Contact: Georgia Office of Insurance and Safety Fire Commissioner Consumer Services Division 2 Martin Luther King, Jr. Drive West Tower, Suite 716 Atlanta, Georgia 30334 (800) 656-2298 http://www.oci.ga.gov/consumerservice/home.aspx Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as minimum essential coverage. This plan or policy does provide minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. 6 of 9
Language Access Services: To see examples of how this plan might cover costs for a sample medical situation, see the next page. 7 of 9
BlueChoice HMO Coverage Period: 01/01/2015 12/31/2015 Coverage Examples Coverage for: Individual/Family Plan Type: HMO About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Having a baby (normal delivery) Amount owed to providers: $7,540 Plan pays $6,970 Patient pays $570 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductibles $0 Copays* $295 Coinsurance $0 Limits or exclusions $0 Total $570 *Copays = Initial maternity office visit of $50, 2 generic prescriptions @ $10 each and facility inpatient copay of $500. Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $4,945 Patient pays $455 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductibles $0 Copays* $455 Coinsurance $0 Limits or exclusions $0 Total $455 *Copays = Seven specialist office visits@ $50 each and three brand name prescriptions @ $35 each. 8 of 9
BlueChoice HMO Coverage Period: 01/01/2015 12/31/2015 Coverage Examples Coverage for: Individual/Family Plan Type: HMO Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs don t include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren t specific to a particular geographic area or health plan. The patient s condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from innetwork providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn t covered or payment is limited. Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor s advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-ofpocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. 9 of 9